Seeking Your Meaningful Use Experiences

The Health IT Policy Committee’s (HITPC) Meaningful Use Workgroup is looking to learn about your meaningful use experiences.

We are hosting two virtual listening sessions – on May 20, 2014 and May 27, 2014 – where we want to hear about your successes and challenges to achieving meaningful use to inform our recommendations for Stage 3 of the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs.

If you are unable to attend either of the listening sessions, please send us your comments in the comment section below.

While the HITPC submitted its stage 3 recommendations to ONC in April 2014, the workgroup wants to gather more input from you – the eligible professionals and hospitals and payers that have been using the new technology and the developers that are creating EHR products.

We are looking to you to share your experiences in developing, adopting, and meaningfully using your electronic health records. Sharing these experiences – with a focus on solutions that can be leveraged in the progression to stage 3 – will help all of us achieve our goals, while optimizing possible stage 3 requirements.

The HITPC recommendations are aimed at supporting new models of care, addressing national health priorities, and addressing key gaps in EHR functionality that are essential to health care providers. To support these goals, four emphasis areas were identified:

Clinical decision support

Patient engagement

Care coordination

Population management

As you think about your comments, you may find the following questions helpful.

Questions:

What has been your experience with achieving stage 1 and what steps or actions are you considering as you approach stage 2? What success factors have you identified?

What should be taken into account as we look toward stage 3 objectives and criteria?

Are there specific areas that should be focused on to provide the most impact in achieving the stage 3 requirements?

What overall benefits have you achieved as a result of implementing and meaningfully using your EHR?

In addition to the comments gathered here, the Meaningful Use Workgroup’s listening sessions will be across the following panels.

15 Comments

We completed Stage 1 of Meaningful Use. We are in the process of Stage 2. We also do E-rx’s when we are able to do so. New York State does not allow controlled substances to go E-rx.

That all being said, I was penalized by Medicare on the first of the year for not doing E-rx’s. I went through to try and figure it out and the only reply that came back was that the Electronic Prescription people/computers do not speak to Medicare. So either Medicare or the E-rx people are retracting payment to providers without really knowing if it is true or not. It took me a while to get it all straightened out and quite honestly, neither Medicare or E-rx office was helpful. In fact, when I received an email advising me of the procedure I was foolish enough to want to speak to a live person. I quickly found out that it was not to be and I should never try to contact a live person again. (slap that hand for wanting to know more)

I wish I could say that Meaningful Use was helpful for the practice. I can’t, at least not in good conscious. Additional burdens for lesser reimbursements so that the government can plan on who will need medical care in the future. Patients out and out lie about conditions. You can smell the cigarette smoke on their jacket and they deny smoking. You politely broach the subject and you are told “it’s no one’s business if I smoke!”.

I believe that in some fashion that the government is trying to force providers to change the “evil ways” of patients. But I can’t help but think that in reality, we are performing actuary services.

I became disillusioned with the whole process with the number of physicians leaving the field due to additional paperwork and Obamacare. It’s not about taking care of patients it’s the numbers game.

As the Health IT Policy Committee (HITPC) Meaningful Use Workgroup considers comments from Meaningful Use users and stakeholders to aid in the progression toward Stage 3, I ask you to consider the addition of sleep assessment as a Meaningful Use Core Objective.

Sleep is vital to health. Sleep assessment, whereby a physician queries a patient regarding sufficient sleep, is a simple but effective means of promoting health, increasing patient engagement, and decreasing cost of care. Further, sleep assessment is applicable to all populations and nearly all medical specialties.

The addition of sleep assessment as a Meaningful Use Core Objective relates directly to several of the emphasis areas identified by the HITPC as supportive of its goals, including:

1. Population management- Sleep disturbance is ubiquitous in the U.S. population because of poor sleep habits and hygiene, symptoms from medical conditions, and sleep disorders. Widespread use of basic sleep assessment would promote health and wellness, prevent potential illnesses, and identify existing conditions.

2. Patient engagement- Recent research has shown that lack of sleep can be a barrier to patient engagement and adherence to medication. In addition, consumers find self-reporting sleep assessment to be a meaningful interaction with their physicians, and it increases patient satisfaction.

3. Clinical decision support- Documentation is available that demonstrates how a sleep assessment Core Objective could be integrated into the flow of patient care, including the availability of support for clinical decision making for nearly all primary care and specialty physicians.

The inclusion of sleep assessment as a Meaningful Use Core Objective would continue to build on the success of parallel Core Objective assessments such as vital signs and tobacco use, which have helped to engage physicians and patients in the meaningful use of health IT and are relevant to standard health assessment. I strongly believe that including sleep assessment in the Meaningful Use program would improve health and health care.

On behalf of the American Academy of Ophthalmology, we thank you for soliciting provider input on the meaningful use program. We believe input from key stakeholders including physicians is critical to the success of the meaningful use program, we and encourage more frequent listening sessions, blog response solicitations, and other mechanisms / forums for gathering provider feedback.

Our answers to your suggested questions are below. The Academy recently submitted a detailed letter to Dr. DeSalvo and Administrator Tavenner with comments on our experiences and feedback on meaningful use program to help shape Stage 3 and improve prior stages. We would be happy to share those comments with your workgroup. Please contact Rebecca Hancock, Manager, Quality and HIT Policy, at rhancock@aaodc.org.

What has been your experience with achieving stage 1 and what steps or actions are you considering as you approach stage 2? What success factors have you identified?

The Academy understands that many of our members will be achieving meaningful use Stage 1 for the first time this year. However, in general, the Academy believes that “all or nothing” is not the right approach for the meaningful use program. We encourage a lower burden option to avoid meaningful use penalties. The current and future meaningful use requirements are problematic, given that failing to meet just one measure by one percent would make a physician ineligible for incentives and subject to the same financial penalties during as physicians who make no effort to adopt EHRs.

Further, the Academy is concerned that the meaningful use program’s requirements are too focused on only a very generalized aspect of primary care, do not recognize existing physician workflows, particularly those who care for the vast number of patients who need more specialized care, and lack the flexibility to accommodate specialists of all types. We encourage CMS to publish data reports on participation in the EHR Incentive Programs, broken down by medical specialty, so we can better understand how a broad range of physicians and other eligible professionals are performing. One size does not fit all. Under the current EHR Incentive Program, every physician regardless of their specialty must meet the same measures (i.e., core measures), and there are few exceptions. The program requirements should be appropriately flexible and better structured to accommodate various practice patterns and specialties. Recognizing participation in an EHR-based national specialty registry is one way to address this issue.

The Academy believes that submission to a national specialty registry could serve as a lower burden option to meet meaningful use while still meeting the program goals of improving quality of care. Physicians who participate in an EHR-based national specialty registry satisfy the program goals of meaningful data capture, advanced care processes, and quality improvement. Use of registries would be a much needed departure from functional objectives. It would be less burdensome for physicians, because data submission is automated and electronic. Registries also offer an enormous value to patients, who benefit from real time physician access to point of care quality data and national benchmarks. We believe that establishing this alternate pathway to avoiding the meaningful use penalties would be an important and meaningful success factor for many physicians.

Regarding Stage 2, the Academy strongly recommends a modification to the Stage 2 CPOE measure, which requires the use of computerized provider order entry (CPOE) for “radiology orders.” We strongly encourage CMS to amend its definition of “radiology order” for the Stage 2 CPOE measure to exclude low risk imaging performed in the physician’s office. We don’t believe that the original intent of “radiology order” was to apply to in-office imaging, and the terminology is not interpreted by most audiences, particularly clinicians, to encompass the testing they provide in their office. CMS requires orders to be entered by “certified medical assistants,” but many ophthalmology offices do not have formally certified technicians or assistants. The high volume of low-risk imaging tests ordered in ophthalmology also makes it extremely burdensome and unrealistic for offices to comply with the Stage 2 CPOE requirement for radiology orders as it is currently defined.

What should be taken into account as we look toward stage 3 objectives and criteria?

The Academy generally encourages that Stage 2 menu set measures are not moved to the Stage 3 core set, or that Stage 2 measures are not revised by increasing thresholds until data on provider performance in Stage 2 is adequately analyzed and assessed, including the impact on patient care. Further, we strongly encourage CMS and ONC to continue to consider the unique needs of a wide array of physicians, and the Academy would welcome the opportunity to work with your workgroup, CMS and ONC in developing appropriate measures for Stage 3 that address these needs for ophthalmologists.

Are there specific areas that should be focused on to provide the most impact in achieving the stage 3 requirements?

Yes. The Academy believes that focus should be directed toward:

1. Addressing the needs of a wide array of physicians by recognizing participation in an EHR-based clinical data registry as an alternative, specialty-specific and more clinically relevant pathway to avoiding the meaningful use penalty. Additionally, we believe focus should be directed to addressing / amending measures that present excessive burden to certain physicians (for example, Stage 2 CPOE measure previously outlined).

2. Aligning of the quality measure portion of the meaningful use program with other quality reporting programs, such as PQRS. Misalignments that exist cause duplication and burdens to providers, and should be avoided when possible. For example, under PQRS, the specifications for quality measures are updated on an annual basis to correct errors and incorporate other updates. However, under meaningful use, updates cannot be made to e-measures on such a frequent basis, and therefore, providers can only report to the version of the e-measure to which their EHR is certified. This is a misalignment between the two programs that should be addressed.

3. Promoting standards-based transmission of patient images, including incorporating the adoption of the Digital Imaging and Communication in Medicine (DICOM) standards. Promoting standards-based transmission of patient images is one area in particular where more robust certification criteria would have tremendous value for physicians, particularly ophthalmologists.

What overall benefits have you achieved as a result of implementing and meaningfully using your EHR?

The Academy believes that there is potential to achieve tremendous value in participating in a specialty data registry through an EHR. The Academy recently launched the IRIS Registry (Intelligent Research in Sight), the nation’s first comprehensive eye disease clinical registry. IRIS Registry uses EHRs to collect and analyze the important data relevant to ophthalmology to provide participants with on demand national and inter-practice benchmark reports. The reports validate the quality of care ophthalmologists provide and pinpoint opportunities for improvement. The IRIS Registry can also collect necessary data, calculate and report on clinical quality measures. Participation in an EHR-based national specialty registry like IRIS Registry will result in the desired goals of meaningful use of Stage 3: improving quality, safety and efficiency, reducing health disparities, and having the ability to query and retrieve data.

I have not participated in MU1 yet, because i do not have a “real” EMR. I have PM software and I scan and shred all paper, and I am paperless in my office. However, as a single/solo/private practice doc, I cannot justify spending 80 to 100k on an EMR when i see no return on that investment other than avoiding a 2 to 5% penalty. I don’t plan to qualify for MU1 or MU2.

This comment is submitted on behalf of the 18,000 members of the College of American Pathologists (CAP), the world’s largest association composed exclusively of board-certified pathologists. While we support the objective of incenting quality care and information exchange through the adaption of interoperable EHRs, the Meaningful Use (MU) program, as we have stated in many official comments since the program’s inception, does not work for pathologists.

 According to the latest information from healthdata.gov dated August 1, 2013, only 652 pathologists (3.4%) have attested to MU. This is not a surprise. MU does not fit pathology practice. Our members generally practice in laboratory information systems (LISs) and not in certified EHRs. They do not conduct office visits or have significant patient face-to-face contact. Most of the objectives in Stage 1 and Stage 2 are outside the scope of pathology practice. The pathologists that have attested to MU are generally at large, integrated academic medical centers where pathologists can “ride” the data of others. The vast majority of our members are in community practice and do not have this option. Further, pathologists cannot control whether they have access to certified EHRs.

 It is odd that pathologists are generally only able to receive MU payment penalties as and are not able to meet program requirements and thereby earn incentives — given that as much as 70% of the information in clinical records is estimated to come from pathologists and their laboratories. Indeed, many of the MU objectives and clinical quality measures depend on laboratory data. Other EPs and hospitals cannot achieve MU without pathologists. Further, pathologists have been using their electronic clinical systems –LISs –since the 1970s.

 In the Final Stage 2 rule, CMS granted pathologists, radiologists and anesthesiologists the significant hardship exception from payment penalties for 2015. Nonetheless, CMS encouraged these specialties to try and meet MU. However, the rules –and the latest Stage 3 recommendations—are written from the perspective of office-based practice. The rules do not fit pathology practice as pathologists generally receive laboratory orders rather than place them.

 We urge CMS to continue the automatic granting of the Significant Hardship Exception for pathologists for the full five years allowed under statute. The bicameral, bipartisan SGR Repeal and Medicare Provider Payment Modernization Act of 2014 acknowledges that non-patient-facing professionals, such as pathologists, are likely unable to meet the current requirements of certain quality programs, including the EHR Meaningful Use Program. Therefore, the bill includes language giving the Secretary of Health and Human Services the flexibility to create measures and activities under the Merit-Based Incentive Payment System that reflect the way pathologists, and other physicians that do not have direct interaction with patients, practice medicine. It’s not too late for the HITPC to work with us to adapt such an approach.

 We also hope that before HHS finalizes many of the laboratory-related Stage 3 objectives, the Department will take advantage of our expertise.

 For instance, pathologists are best suited to provide advice on how to implement the clinical decision support rule around the appropriateness of laboratory orders and allows for deference to the pathologist’s judgment and ability to advise other clinicians on appropriate test ordering. A study in the March-April 2014 edition Journal of the American Board of Family Medicine, based on a CDC survey, found that of general internal medicine and family physicians, 14.7%reported uncertainty about ordering tests and uncertainty in interpreting results in 8.3% of these diagnostic encounters. However, while the study recommended improvements in clinical decision support, it also said that quick access to laboratory consultations would be helpful.

 Additionally, we are concerned certification criterion mandating that the “EHR should display the abnormal flags for test results if it is indicated in the lab-result message.” The CAP has questions as to how the EHR will define “abnormal” and in ensuring that in defining “abnormal,” the EHR doesn’t miss important results or lead ordering physicians to believe they can ignore results not tagged as “abnormal” by the EHR. The EHR typically identifies “abnormal” results based on what is sent from the laboratory. Just because EHRs “can” identify abnormal results, does not mean that all abnormal results are identified as such. This is a complex issue. Defining “abnormal” will depend on: 1) the type of result and 2) test definitions in the LIS and the EHR. Result types that involve significant text (such as surgical pathology reports or test results that are interpretive in nature), results like microbiology (especially a challenge), and results that have complex or conditional “normal” ranges (e.g. endocrine stimulation tests, drug levels, tumor markers) cannot be easily defined in the LIS or the EHR to have a simple binary normal/abnormal criteria that the LIS or EHR rules engine typically requires to use to “trigger” the use of an abnormal flag. Test results can be out of the reference range, or can be positive or negative for a particular analyte/organism, etc. There is no way to determine whether a result is “abnormal” in a particular situation. Pathologist input is essential at all sites where this is employed so as to avoid potential patient safety issues.

 We look forward to working with you to improve the MU program for the patients that we serve. Our members should not be penalized for failing to comply with a program that they cannot meet through no fault of their own. Thank you.

Stage 2 MU: 2 problems for me-
1. I have Practice Fusion as my EHR. My hospital, Vidant Roanoke Chowan Hospital in Ahoskie, has Epic healthspan as EHR. These two don’t have interoperability so I can’t send and receive Lab/Imaging orders and reports
2. I don’t know how to make my patients receive, download and reply their health records because I practice in rural area with 75% of my patients Medicare-Medicaid who don’t have computers computer literacy or ability to afford broadband even though available.
Even though I like EHR but I definitely know I am set up for failure to meet Core & Menu objectives.

Am I to understand you are not a member of Vidant Medical Group nor is your practice owned by Vidant Medical Groups? Has Vidant approached you about leasing their EHR Epic system so you can connect to the local Vidant physicians/practices and the Hospital?

Unfortunately MU is focused on primary care issues. Why does a patient need all the ridiculous things that need to be done for MU done by multiple physicians managing the same patient. How many copies of the patient’s medication list do they need? Keeping in mind that the list was initially provided by the patient. We begrudgingly participated in the program. We hate it and if there was any way to not do it we would. But when one works for a large health system there are enough bean counters who will come tell us so we have to do it. This does not in any way help patients. Some lawyer in Washington thought it was a good idea. That’s it. Not any person who sees 20-30 patients a day could come up with such garbage. I hope more MDs stop accepting Medicare as that is the only solution to this problem.

Our Otolaryngology practice embraced EHR several years ago, and achieved stage 2 meaningful use with Allscripts this year. However I doubt we will achieve stage 3 as we could barely find requirements to fit a specialty practice. Otolaryngology is a small and unique specialty. There is no flexibility in the requirements to improve care for the chronic conditions we address. For instance, the required patient education handouts supplied by Allscripts are too general to be useful, but the handouts designed by the American Academy of Otolaryngology do not count toward meaningful use. Please do not ignore specialists in writing these guidelines.

Our office embraced EHR technology several years ago, with updates as new features became available. As a single speciality Otolaryngology practice, we managed to achieve stage 1 and 2 meaningful use. We had great difficulty finding enough sections in stage 2 that applied to our practice, as they are all geared toward family practice/internal medicine. Please make specialty specific guidelines for stage 3. I am sure the Academy of Otolaryngology can come up with approaches that will improve Otolaryngology patient care. For instance, all the care goals have nothing to do with anything we do in our office. I am sure Ophthalmology and other surgical specialties have the same problem.
We have had a patient web portal for quite a while, but our elderly and unsophisticated rural population mostly does not even own a computer, so usage is low. Rural patients are Not computer savvy.
Thank you for your consideration.

EHR adoption important to long-term care.
It’s not about checking the dots, getting these incentives, and chasing grant money,” . “We find that this space is really motivated by improving your own financial, operational outcomes; minimizing risk or potential litigation; and with ultimately improving and enriching the lives of the seniors that they provided services to.”
While the lack of meaningful use incentives to long-term care providers has not helped adoption among these specialists, it has actually presented some advantages.
“What’s great about our space specifically in senior living not being covered in meaningful use is that it is actually moving forward with EHR not because of incentives but because it actually has a meaningful impact on their business,

I believe that the Stage 2 criteria concerning electronic patient communications are unduly strict, discriminatory against underprivileged populations, and based on incomplete, or insufficient data and experience:

“Published experiences and initial studies of doctors and their staff attesting to this measure have shown success far above the 5% threshold. We set the low threshold of 5% because we recognize that certain patient populations present greater challenges than others, and we do not have any reliable way to quantify these populations for each EP. We believe that EPs’ ability to influence patients coupled with the low threshold of more than 5 percent of patients having viewed online, downloaded, or transmitted to a third party the patient’s health information make this measure achievable for all EPs.”
~~Do those public experiences include experiences in patient populations that are simultaneously ALL of the following: geriatric, low education, non-English speaking, and low-income? Today, a typical day, of the 13 patients I saw, they were aged 84, 81, 80, 79, 73, 72, 71, 70, 67, 66, 60, 50, and 32. All except the 32 year old are primarily Chinese speaking, the vast majority of them do not read or write English, and cannot even fill out our paper registration forms without assistance. None, except the 32 year old, utilize a computer for any personal purpose. Most do not have internet access or own a computer. 1/3 of them live in single-room occupancy housing. Most do not own smartphones. Many do not use any kind of cell phone. But, the vast majority of them still live independently and manage their own daily affairs, and come to medical appointments on their own, and handle all their own medical-related communications, so there is no “authorized representative” that I would normally be communicating with, other than for the contrived purpose of trying to find someone to access the patient portal on behalf of the patient. The 32-year old came in for simple flu symptoms, had no issues that would expect follow up communications, and declined giving me an email address in order to access the patient portal.

By my best estimate, at most only about 5% of my patients have any realistic chance of meaningfully accessing a patient portal. Of those, I have already come across a several that have declined because they do not want another password to manage and are concerned about privacy issues accessing their data online, handling yet another password, etc. In two months, I have gotten 9 patients to access the portal. That is nowhere near 5%.

To reach 5%, I anticipate I will have to pressure patients to provide me with an “authorized representative” who can give me and email address and cell phone number purely for the contrived purpose of enabling me to send them an invitation to the patient portal. As mentioned in my original message, many of my patients are so old that even their children are geriatric, limited-English speaking, and not online. So then I would have to resort to asking the grandchildren to access the patient portal. This is harmful in at least a couple of ways. It infringes on my patients’ rights to be in charge of their own medical affairs, and it leads to potential miscommunication. If lab results come back and I want to inform my patient of any abnormal results, and tell them which medicine they need to adjust, is it better for me to call the patient directly in a non-electronic communication, or is it better for me to send a message via the patient portal to their grandson in high school who only sees the patient once a month, for him to read in English then try to translate into Chinese and explain secondhand to the patient??

Alternately, one of my staff will literally have to sit patients down in front of a computer, walk them through how to set up an email account that they will never again use for any other purpose keystroke by keystroke, then help them set up a patient portal account once we send an invitation to their email address. For no purpose other than to meet the meaningful use percentages.

“The denominator for both measures is defined as the “number of unique patients seen by the EP during the EHR reporting period.” The first measure’s numerator is “the number of patients in the denominator who have timely (within 4 business days after the information is available to the EP) online access to their health information.” The use of the term “available” indicates that this measure may be met without the patient accessing it. In fact, this could include providing patients with instructions on how to access their health information, the website address they must visit for online access, a unique and registered username or password, instructions on how to create a login, or any other instructions, tools, or materials that patients need in order to view, download, or transmit their information. There is no requirement that the patient request the information, provide an email address or do anything to go online and create an account. As long as the patient is given the information, he/she would still be counted in meeting the first measure.”
~~My EHR is certified. For a patient to access the patient portal, they need an invitation from me, and then they set up an account. For the purposes of privacy and security, in order to invite a patient to set up an account, my EHR requires them to provide both a cell phone number and an email address. Although CMS does not require the patient to provide an email address, my EHR software requires it in order to access the patient portal. So, if the vast majority of my patients as described in the paragraph above do not own computers and smartphones, do not have internet access, do not use email or have email addresses, and do not read or write English (which is what language the information in the EHR will be written in), but are competent and in charge of their own medical affairs, why would I even consider offering them information about the patient portal??

“CMS believes that EPS are in a unique position to strongly influence the technologies patients use to improve their own care, including viewing, downloading, and transmitting their health information online.”
~~Given all the above, I can say with certainty that the percentage of my patients who realistically have any chance of accessing a patient portal is much less than 50%, whatever I do to try to influence them. Unless you expect me to help them move them out of an SRO into better housing so they have room for a computer (I’ve had patients who can barely walk adamantly refuse ordering a wheelchair because they didn’t have space in their SRO to fit one), buy them a computer, install internet access for them, and teach them English. However, in order not to be financially penalized in the meaningful use program, this stringent criteria of providing access to at least 50% of my patients means that I will have to either waste my or my staff’s time telling my patients about a patient portal that they have no realistic way of accessing, or waste resources printing out handouts to give the with information about the patient portal that they will not read or be able to use. Time and resources that could be put to better use actually benefitting the patients by more time for actual counseling and education for the patients, communicating with other providers, looking things up, reading, continuing education. This is a socio-economic-educational issue that is beyond the scope and responsibility of a physician’s medical practice. If the use of online information access is so crucial to people’s wellbeing, then the government needs to put in place other infrastructure, resources, and mechanisms to get underprivileged communities online, outside the realm of healthcare.

I would like to wholeheartedly agree with the comments regarding 5% portal adoption and secure messaging. I manage a pediatric practice in rural North Carolina with 60% Medicaid patients. Many do not have a computer. Some may have a smart phone, but change their phone numbers and e-mail addresses frequently. Many admit to not looking at their e-mail, and do not wish to receive notices that way. My system also requires e-mail addresses and phone numbers to access the portal. Then there is the problem of them not remembering their password because they visit the portal infrequently. They have also been accustomed to calling our office and getting help and answers from a live person, and find it cumbersome and time consuming to have to turn on the computer, log in, and look around for something they could have from us by pressing one button on their phone from their contacts.

We too, have hired extra help to walk patients through the process of enrolling in the portal and sending a secure message – it seems like a ridiculous effort when we have so many more important tasks involved in direct patient care for our kids.

We should not have to meet a measure that relies completely on the cooperation of patients. That is completely unrealistic and has proved to be not only an extreme burden on primary care practices, but most likely unachievable and will prevent us from receiving our Stage 2 funds.

I have a real concern about the portal usage. If a patient does not use computers is it within the realm of the law to let these people still call for appointments or whatever. Are they fined or the provider fined ? i have heard patients tell me that if they do not use the portal they cannot make appointments you are allowed 3 times and then they have to be using the portal. Had one patient whom does use the portal to view their records and labs, but told us she feels it is very impersonal to make an appointment this way. That she will continue to call for appointments, she will not request via portal or email. Can and will she be turned away, Or charged with fines, or the provider is charged with fines. I feel the portal is good in someways but it should be offered to the patients if they want to use it. I feel most will use it but there are places lower income that do not have the funds to use computers. and what about the elderly? This meaningful use i feel is getting out of hand and some will stop seeking help for health problems. I am very concerned and want to make provisions for those less fortunate. It is not just black and white there is gray areas. Each human being is different with different needs. please let me know if there is a federal regulation. i am trying to help solve a conflicting situation with and better solution that will benefit all. thankyou for your time.

I work in a Radiation Oncology office and most of our patients are over the age of 65 and don’t have an email. We aren’t compliant for meaningful use if we don’t put in an email address. Is there a solution for this? Can we use a generic email if they don’t have one? Or do we just stay non-compliant.